Geographical distribution of surgical capabilities and disparities in the use of high-volume providers: the case of coronary artery bypass graft.
ABSTRACT Previous studies have documented substantial differences by patient race/ethnicity and insurance in the use of high-volume surgical providers. The extent to which regional availability of surgical capabilities explains such differences has not been examined.
To examine the existence of racial/ethnic and payer differences in using high-volume hospitals and surgeons for coronary artery bypass graft (CABG) in the state of Florida and to study the role of regional availability of high-volume providers in explaining the differences.
We conducted descriptive analysis of the distribution of CABG providers and patient populations by race/ethnicity and insurance across the 19 Hospital Referral Regions (HRRs) in Florida. We estimated logistic regressions of using a high-volume provider to derive estimates of overall group differences. We further estimated models with HRR fixed effects to derive within-HRR differences. We derived implications by comparing findings based on the 2 sets of models.
Non-Hispanic black patients were 58% as likely (95% CI: 52%, 65%), Hispanic patients were 84% as likely (95% CI: 77%, 90%), to have received CABGs at a high-volume hospital, compared with non-Hispanic whites. Controlling for inter-HRR differences eliminated almost all racial/ethnic differences. Substantial differences in using high-volume providers existed between Medicaid/uninsured and privately insured patients and such differences persisted within HRRs.
Unequal distribution of CABG capabilities coupled with racial/ethnic concentration in residence across Florida HRRs accounted for almost all racial/ethnic differences in using high-volume hospitals. Factors other than availability of surgical resources were responsible for differences between Medicaid/uninsured and privately insured patients.
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ABSTRACT: While disparities in hospital care outcomes based on ethnicity or socioeconomic status have been documented in some nations, it is unclear to what extent this phenomenon occurs in high-income countries like Korea with relatively low income inequality. We examined in-hospital mortality rates for wealthy and poor patients in South Korea for five common medical conditions. We measured in-hospital mortality rates and examined within-hospital differences (wealthy and poor patients receive different care at the same institution) as well as between-hospital differences (wealthy and poor patients receiving care at different institutions) across socioeconomic status. We built multivariable models that adjusted for risk and further adjusted our analyses for hospital characteristics including a hospital's overall mortality ranking. There were 127 438 patients with one of the five conditions examined nested in 66 Korean hospitals. We found moderate differences in mortality rates between wealthy and poor patients across four of the five conditions. These mortality differences were largely attributable to differences in mortality rates for wealthy patients compared with those for poor patients within the same hospital (within-hospital variation) while a relatively small portion of these disparities were attributable to mortality difference between hospitals where wealthy and poor patients seek care (between-hospital variation). For example, we estimate that improving care for poor patients in the same hospital can eliminate 86% of the disparities for acute myocardial infarction outcomes, while ensuring equal access to low mortality hospitals would reduce only 16% of the disparities in outcomes. This study suggests that to reduce socioeconomic disparities in hospital mortality, interventions that target within-hospital effects may be more effective than interventions targeting between hospital effects.BMJ quality & safety 03/2014; 23(9). DOI:10.1136/bmjqs-2013-002744 · 3.28 Impact Factor
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ABSTRACT: Within Southwestern Ontario, abdominal aortic aneurysm (AAA) surgery has been centralized to a single university-affiliated medical center. The referral area serves 1.9 million people and includes community hospitals with limited vascular surgery capabilities. We reviewed the role of patients' travel distance, geographic location, and socioeconomic status (SES) to determine if centralization of endovascular programs results in disparity in access to endovascular surgery. We hypothesized that patients would travel a longer distance to specifically seek elective endovascular surgery while having open and emergent surgery closer to home. All patients who underwent AAA repair (July 2005-June 2010) at London Health Science Centre were identified from the vascular surgery database. Method of repair, clinical presentation, and in-hospital mortality were recorded. Travel distance from each patient's home to our hospital and rural versus urban status was determined for each patient. SES was determined by using a previously validated, locally developed deprivation index. During this 5-year period, 1,243 patients were included in our analysis; 46.8% (n = 581) underwent endovascular repair (EVAR) and 53.2% (n = 662) underwent open repair. For elective cases, the in-hospital mortality rate was 2.0% (n = 11) for EVAR and 3.6% (n = 20) for open repair (P = 0.1). There was no difference in clinical presentation between SES groups, but open repair was more frequently used in patients of lower SES compared to higher SES (odds ratio = 1.32; 95% confidence interval: 1.02-1.72). Travel distance and rural/urban status were not associated with increased odds of EVAR. When ruptured aneurysms were excluded, elective patients of lower SES continued to have a higher rate of open surgery. Despite the centralization of endovascular programs in Canada, patients do not appear to be traveling a longer distance for EVAR while having open repairs closer to home as we expected. We did note that higher SES was associated with increased odds of EVAR, which may suggest a health care access bias for EVAR for patients of higher SES. Larger, population-based studies at the provincial or national level could confirm these initial findings.Annals of Vascular Surgery 09/2013; 27(8). DOI:10.1016/j.avsg.2013.02.020 · 1.03 Impact Factor
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ABSTRACT: ACC/AHA guidelines recommend STEMI patients receive percutaneous coronary intervention (PCI) at high volume hospitals performing ≥400 procedures/year. The objective of this study was to evaluate changes in the organization and implementation of care for STEMI patients in Florida. We assessed trends and predictors of STEMI patients first hospitalized at high PCI volume hospitals in Florida from 2001-2009. This is the first study to examine statewide trends in hospital admission for all STEMI patients. We classified Florida hospitals by PCI volume (high, medium, low, non-PCI) for each quarter from January, 2001 through June, 2009. Using hospital discharge data, we determined the percent of STEMI patients who went to each type of hospital and analyzed multiple predictors. From 2001-2009 the proportion of STEMI patients first hospitalized at high PCI volume hospitals rose from 62.4 to 89.7%, while admissions to non-PCI hospitals declined from 31% to 4.9%. Persistent barriers to high PCI volume hospital admission were age ≥85 years (OR 0.56, 95% CI 0.50-0.62), female gender (OR 0.85, 95% CI 0.79-0.91), and residence in a major metropolitan county. Through the efforts of local coalitions throughout Florida, by 2009 almost 90% of Florida STEMI patients were first admitted to high PCI volume hospitals. Greater hospital competition may explain lower admission rates to high PCI volume hospitals in major metropolitan counties. The age and gender disadvantage we observed requires further research to determine potential causes.American heart journal 11/2012; 164(5):681-8. DOI:10.1016/j.ahj.2012.06.027 · 4.56 Impact Factor